Joseph Hildner, MD, FAAFP, spoke Friday at the AAFP Annual Scientific Assembly on the importance of shared decision making among patients and physicians, the proper role and forum for patient education, and the barriers to effective communication that can make it difficult for patients to make fully informed decisions about their care.
Hildner spent the early portion of his well-received presentation, titled “Well Doc, What Would YOU Do? Empowering Patients to Make Educated Decisions,” defining shared decision making. Shared decision making works, stated Hildner, because it improves outcomes, improves patient satisfaction with the care experience, and fosters a stronger patient—physician relationship. He offered a variety of alternative definitions for the term (including “relationship-centered decision making”) that stressed the central importance of a strong patient–physician relationship and effective communication (more on that in a minute) in creating an environment that will not only allow patients to understand the options available to them and the possible ramifications of the treatment decisions they make with their physician, but also ensure that physicians understand their patients’ concerns, values, and priorities regarding treatment. Hildner was careful to also discuss what shared decision making is not; it’s not merely informed consent or patient education—it encompasses the entire process of consultation, teaching, recommending, and listening that characterizes effective family medicine.
Not all patients are ready to become fully active participants in their care, though. A substantial percentage are still eager to place themselves entirely in their physicians’ hands and trust his or her medical judgment. A growing percentage of patients, however, expect a different process entirely and arrive at the office armed with information, printouts, and definite opinions and ideas about exactly what they think should be done to and for them. It’s almost as if these patients want to treat themselves, said Hildner, and only need their physician for his or her medical license. To that end, Hildner remarked that physicians should only pursue shared decision making to the extent that the patient is comfortable with the responsibilities and requirements of the process.
If shared decision making requires that the patient possesses the necessary information to make an educated decision, what exactly is required of physicians who wish to promote this process? Hildner noted that a major limiting factor is the quantity and complexity of the issues and information that a diligent physician is expected to discuss with patients (he used the USPS recommendations for prostate screening and hormone replacement therapy for the prevention of chronic conditions in postmenopausal women as examples of this). With severe limitations on the amount of time many physicians can spend in one office visit with a patient, this poses a daunting challenge, especially when dealing with patients with little prior knowledge of the subject. Low levels of patient literacy and numeracy, complexity of terminology and concepts (ever try discussing relative risk with a patient?), the limiting factors of the disease itself, and the hazards of language (what patients hear and/or understand vs. what a physician intended to say/thought he or she said) all conspire against effective shared decision making to the point that it is often impossible to have a comprehensive discussion in the office with a patient that covers all issues and subjects that patients must know and consider in order to make an informed decision.
So what’s a physician to do? Hildner said that physicians should not be afraid to challenge patients to do a little homework, as he put it, and come prepared to discuss his or her options. This can mean a return visit once the patient has done some guided research; or even better, patients can be directed to useful information prior to the office visit, especially if the practice has an effective Web portal and pre-visit screening procedures in place. Ideally, said Hildner, the office visit should be reserved for discussing and deciding, not prepping the patient on the basic issues at hand.
The Internet is invaluable in this capacity, offering a growing number of accurate, reliable, patient-friendly educational resources. Hildner cited several as being particular favorites of his, including The Risk Communication Institute (www.riskcomm.com), which features a variety of visual aids, presentations, and other resources that can be used to help patients understand the risks associated with diseases and treatments; InformedMedicalDecisions.org (www.informedmedicaldecisions.org), which offers a large library of educational resources that “organize and frame medical evidence in an unbiased manner to help patients evaluate their options;” and WiredMD (www.wiredmd.com). He also noted that YouTube (www.youtube.com) now also hosts an impressive and growing collection of physician- and healthcare-organization-created patient education videos and tutorials. Physicians surely should take the time to review the content of any site or online resource to which they direct patients, but compiling a go-to library of trusted content can save time for busy physicians and provide patients with the foundation upon which to participate in the shared decision-making process.